Provider Demographics
NPI:1447640081
Name:SOROURI, SOGHRA
Entity type:Individual
Prefix:DR
First Name:SOGHRA
Middle Name:
Last Name:SOROURI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6838 N KILPATRICK AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-2437
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6838 N. KILPATRICK AVE
Practice Address - Street 2:
Practice Address - City:LINCOLWOOD
Practice Address - State:IL
Practice Address - Zip Code:60712
Practice Address - Country:US
Practice Address - Phone:847-329-7719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-04
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-024208122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist